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What are the repercussions of disclosing a medical error?
Physicians and their staff may experience a resolution of anxiety and guilt that can improve their well-being (strength of recommendation [SOR]: C, based on survey data). Full disclosure has little effect, however, on the likelihood that an injured patient will seek legal counsel (SOR: C, based on survey data). Successful disclosure of a medical error can improve a patient’s confidence in the physician and lead to improved outcomes (SOR: C, based on expert opinion).
Disclosure is preventive medicine against future errors
Kevin E. Johnson, MD
New Hanover Regional Medical Center, Residency in Family Medicine, Wilmington, NC
Disclosing a medical error is one of the least pleasant tasks a physician can face. It is even more difficult if we perceive the error as someone else’s fault. As family physicians, we may be the leaders of “Team Healthcare,” but we win, lose, and make errors as part of a team. Only through sharing ownership of an error does a team feel supported by each other and their leaders.
Sharing allows a dialogue for positive change to occur. When we use blame and denial as our defense, no one wins. Acknowledging errors when they occur and disclosing them fully is the only preventative medicine we can offer against future errors.
Evidence summary
Surveys suggest that patients prefer a detailed disclosure
Our review of the medical literature since 2000 found 238 articles regarding disclosure of medical errors. Of these, 17 contain empirical data. There have been no randomized controlled trials regarding the effects of disclosure, and evidence is limited about the best method for carrying out a disclosure or the consequences of disclosure in clinical settings.
The 17 studies we selected all presented case scenarios involving medical errors—either as surveys or in focus groups—to physicians or lay persons. Respondents were asked to imagine a given scenario and then describe the feelings or emotions that were generated by specific errors, whether disclosures should be made, and whether disclosure affects the likelihood of patients seeking legal advice.
Survey data suggest that patients prefer detailed disclosure about what happened, why it happened, the consequences, and strategies for preventing future errors.1-4 Regardless of whether a full disclosure occurred, patients are more likely to seek legal advice if they perceive the error as having serious consequences.2,5
Physicians and nurses describe negative emotional consequences when they realize they have made an error.6-7 They discuss errors among themselves, but are reluctant to disclose errors to patients.8
Even though physicians feel that disclosure of errors is important, they may lack the skills to make a successful disclosure or feel they do not have institutional support for disclosure.9 Most data suggest that physician well-being is improved by discussion of errors with patients and colleagues.1,10
Legal ramifications of disclosure are unclear
Very little evidence exists regarding the effect of disclosure on the likelihood of legal action in actual practice.5 Eighty-five percent of respondents to one survey indicated that financial compensation of patients affected by medical errors is appropriate. But the spectrum of repercussions can vary from waiving charges for minor incidents to considering early settlement in serious cases.2
Recommendations from others
Disclosure of medical errors is recommended by numerous medical ethicists and is a key component of patient safety initiatives. Guidelines developed in Australia are in the TABLE.11
The American Medical Association’s Code of Ethics states: “Physicians must offer professional and compassionate concern toward patients who have been harmed, regardless of whether the harm was caused by a health care error. An expression of concern need not be an admission of responsibility. When patient harm has been caused by an error, physicians should offer a general explanation regarding the nature of the error and the measures being taken to prevent similar occurrences in the future. Such communication is fundamental to the trust that underlies the patient-physician relationship, and may help reduce the risk of liability.”10
TABLE
How to manage a medical error
|
| Source: Australian Commission on safety and quality in Health Care, 2003. 11 |
1. Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA 2003;289:1001-1007.
2. Mazor KM, Reed GW, Yood RA, Fischer MA, Baril J, Gurwitz JH. Disclosure of medical errors: what factors influence how patients will respond? J Gen Intern Med 2006;21:704-710.
3. Evans SM, Berry JG, Smith BJ, Esterman AJ. Anonymity or transparency in reporting of medical error: a community-based survey in south Australia. Med J Aust 2004;180:577-580.
4. Schwappach DLB, Koeck CM. What makes an error unacceptable? A factorial survey on the disclosure of medical errors. Int J Qual Health Care 2004;16:317-326.
5. Kachalia A, Shojania KG, Hofer TP, Piotrowski M, Saint S. Does full disclosure of medical errors affect malpractice liability? The jury is still out. Jt Comm J Qual Saf 2003;29:503-511.
6. Chan DK, Gallagher TH, Reznick R, Levinson W. How surgeons disclose medical errors to patients: a study using standardized patients. Surgery 2005;138:851-858.
7. Hingorani M, Wong T, Vafidis G. Patients’ and doctors’ attitudes to amount of information given after unintended injury during treatment: cross sectional, questionnaire survey. BMJ 1999;318:640-641.
8. Hobgood C, Xie J, Weiner B, Hooker J. Error identification, disclosure, and reporting: practice patterns of three emergency medicine provider types. Acad Emerg Med 2004;11:196-199.
9. Waring JJ. Beyond blame: cultural barriers to medical incident reporting. Soc Sci Med 2005;60:1927-1935.
10. American Medical Association. Code of ethics. E-8.121: Ethical responsibility to study and prevent error and harm. Available at: www.ama-assn.org/ama/pub/category/11968.html. Accessed January 22, 2008.
11. Australian Commission on safety and quality in Health Care. Open Disclosure: Health Care Professionals Handbook. Canberra: Commonwealth of Australia; 2003. Available at: www.safetyandquality.org/internet/safety/publishing.nsf/Content/6B75B6A3eA43Ce0FCA2571D50001e19D/$File/hlthcareprofhbk.pdf. Accessed January 7, 2008.
Physicians and their staff may experience a resolution of anxiety and guilt that can improve their well-being (strength of recommendation [SOR]: C, based on survey data). Full disclosure has little effect, however, on the likelihood that an injured patient will seek legal counsel (SOR: C, based on survey data). Successful disclosure of a medical error can improve a patient’s confidence in the physician and lead to improved outcomes (SOR: C, based on expert opinion).
Disclosure is preventive medicine against future errors
Kevin E. Johnson, MD
New Hanover Regional Medical Center, Residency in Family Medicine, Wilmington, NC
Disclosing a medical error is one of the least pleasant tasks a physician can face. It is even more difficult if we perceive the error as someone else’s fault. As family physicians, we may be the leaders of “Team Healthcare,” but we win, lose, and make errors as part of a team. Only through sharing ownership of an error does a team feel supported by each other and their leaders.
Sharing allows a dialogue for positive change to occur. When we use blame and denial as our defense, no one wins. Acknowledging errors when they occur and disclosing them fully is the only preventative medicine we can offer against future errors.
Evidence summary
Surveys suggest that patients prefer a detailed disclosure
Our review of the medical literature since 2000 found 238 articles regarding disclosure of medical errors. Of these, 17 contain empirical data. There have been no randomized controlled trials regarding the effects of disclosure, and evidence is limited about the best method for carrying out a disclosure or the consequences of disclosure in clinical settings.
The 17 studies we selected all presented case scenarios involving medical errors—either as surveys or in focus groups—to physicians or lay persons. Respondents were asked to imagine a given scenario and then describe the feelings or emotions that were generated by specific errors, whether disclosures should be made, and whether disclosure affects the likelihood of patients seeking legal advice.
Survey data suggest that patients prefer detailed disclosure about what happened, why it happened, the consequences, and strategies for preventing future errors.1-4 Regardless of whether a full disclosure occurred, patients are more likely to seek legal advice if they perceive the error as having serious consequences.2,5
Physicians and nurses describe negative emotional consequences when they realize they have made an error.6-7 They discuss errors among themselves, but are reluctant to disclose errors to patients.8
Even though physicians feel that disclosure of errors is important, they may lack the skills to make a successful disclosure or feel they do not have institutional support for disclosure.9 Most data suggest that physician well-being is improved by discussion of errors with patients and colleagues.1,10
Legal ramifications of disclosure are unclear
Very little evidence exists regarding the effect of disclosure on the likelihood of legal action in actual practice.5 Eighty-five percent of respondents to one survey indicated that financial compensation of patients affected by medical errors is appropriate. But the spectrum of repercussions can vary from waiving charges for minor incidents to considering early settlement in serious cases.2
Recommendations from others
Disclosure of medical errors is recommended by numerous medical ethicists and is a key component of patient safety initiatives. Guidelines developed in Australia are in the TABLE.11
The American Medical Association’s Code of Ethics states: “Physicians must offer professional and compassionate concern toward patients who have been harmed, regardless of whether the harm was caused by a health care error. An expression of concern need not be an admission of responsibility. When patient harm has been caused by an error, physicians should offer a general explanation regarding the nature of the error and the measures being taken to prevent similar occurrences in the future. Such communication is fundamental to the trust that underlies the patient-physician relationship, and may help reduce the risk of liability.”10
TABLE
How to manage a medical error
|
| Source: Australian Commission on safety and quality in Health Care, 2003. 11 |
Physicians and their staff may experience a resolution of anxiety and guilt that can improve their well-being (strength of recommendation [SOR]: C, based on survey data). Full disclosure has little effect, however, on the likelihood that an injured patient will seek legal counsel (SOR: C, based on survey data). Successful disclosure of a medical error can improve a patient’s confidence in the physician and lead to improved outcomes (SOR: C, based on expert opinion).
Disclosure is preventive medicine against future errors
Kevin E. Johnson, MD
New Hanover Regional Medical Center, Residency in Family Medicine, Wilmington, NC
Disclosing a medical error is one of the least pleasant tasks a physician can face. It is even more difficult if we perceive the error as someone else’s fault. As family physicians, we may be the leaders of “Team Healthcare,” but we win, lose, and make errors as part of a team. Only through sharing ownership of an error does a team feel supported by each other and their leaders.
Sharing allows a dialogue for positive change to occur. When we use blame and denial as our defense, no one wins. Acknowledging errors when they occur and disclosing them fully is the only preventative medicine we can offer against future errors.
Evidence summary
Surveys suggest that patients prefer a detailed disclosure
Our review of the medical literature since 2000 found 238 articles regarding disclosure of medical errors. Of these, 17 contain empirical data. There have been no randomized controlled trials regarding the effects of disclosure, and evidence is limited about the best method for carrying out a disclosure or the consequences of disclosure in clinical settings.
The 17 studies we selected all presented case scenarios involving medical errors—either as surveys or in focus groups—to physicians or lay persons. Respondents were asked to imagine a given scenario and then describe the feelings or emotions that were generated by specific errors, whether disclosures should be made, and whether disclosure affects the likelihood of patients seeking legal advice.
Survey data suggest that patients prefer detailed disclosure about what happened, why it happened, the consequences, and strategies for preventing future errors.1-4 Regardless of whether a full disclosure occurred, patients are more likely to seek legal advice if they perceive the error as having serious consequences.2,5
Physicians and nurses describe negative emotional consequences when they realize they have made an error.6-7 They discuss errors among themselves, but are reluctant to disclose errors to patients.8
Even though physicians feel that disclosure of errors is important, they may lack the skills to make a successful disclosure or feel they do not have institutional support for disclosure.9 Most data suggest that physician well-being is improved by discussion of errors with patients and colleagues.1,10
Legal ramifications of disclosure are unclear
Very little evidence exists regarding the effect of disclosure on the likelihood of legal action in actual practice.5 Eighty-five percent of respondents to one survey indicated that financial compensation of patients affected by medical errors is appropriate. But the spectrum of repercussions can vary from waiving charges for minor incidents to considering early settlement in serious cases.2
Recommendations from others
Disclosure of medical errors is recommended by numerous medical ethicists and is a key component of patient safety initiatives. Guidelines developed in Australia are in the TABLE.11
The American Medical Association’s Code of Ethics states: “Physicians must offer professional and compassionate concern toward patients who have been harmed, regardless of whether the harm was caused by a health care error. An expression of concern need not be an admission of responsibility. When patient harm has been caused by an error, physicians should offer a general explanation regarding the nature of the error and the measures being taken to prevent similar occurrences in the future. Such communication is fundamental to the trust that underlies the patient-physician relationship, and may help reduce the risk of liability.”10
TABLE
How to manage a medical error
|
| Source: Australian Commission on safety and quality in Health Care, 2003. 11 |
1. Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA 2003;289:1001-1007.
2. Mazor KM, Reed GW, Yood RA, Fischer MA, Baril J, Gurwitz JH. Disclosure of medical errors: what factors influence how patients will respond? J Gen Intern Med 2006;21:704-710.
3. Evans SM, Berry JG, Smith BJ, Esterman AJ. Anonymity or transparency in reporting of medical error: a community-based survey in south Australia. Med J Aust 2004;180:577-580.
4. Schwappach DLB, Koeck CM. What makes an error unacceptable? A factorial survey on the disclosure of medical errors. Int J Qual Health Care 2004;16:317-326.
5. Kachalia A, Shojania KG, Hofer TP, Piotrowski M, Saint S. Does full disclosure of medical errors affect malpractice liability? The jury is still out. Jt Comm J Qual Saf 2003;29:503-511.
6. Chan DK, Gallagher TH, Reznick R, Levinson W. How surgeons disclose medical errors to patients: a study using standardized patients. Surgery 2005;138:851-858.
7. Hingorani M, Wong T, Vafidis G. Patients’ and doctors’ attitudes to amount of information given after unintended injury during treatment: cross sectional, questionnaire survey. BMJ 1999;318:640-641.
8. Hobgood C, Xie J, Weiner B, Hooker J. Error identification, disclosure, and reporting: practice patterns of three emergency medicine provider types. Acad Emerg Med 2004;11:196-199.
9. Waring JJ. Beyond blame: cultural barriers to medical incident reporting. Soc Sci Med 2005;60:1927-1935.
10. American Medical Association. Code of ethics. E-8.121: Ethical responsibility to study and prevent error and harm. Available at: www.ama-assn.org/ama/pub/category/11968.html. Accessed January 22, 2008.
11. Australian Commission on safety and quality in Health Care. Open Disclosure: Health Care Professionals Handbook. Canberra: Commonwealth of Australia; 2003. Available at: www.safetyandquality.org/internet/safety/publishing.nsf/Content/6B75B6A3eA43Ce0FCA2571D50001e19D/$File/hlthcareprofhbk.pdf. Accessed January 7, 2008.
1. Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA 2003;289:1001-1007.
2. Mazor KM, Reed GW, Yood RA, Fischer MA, Baril J, Gurwitz JH. Disclosure of medical errors: what factors influence how patients will respond? J Gen Intern Med 2006;21:704-710.
3. Evans SM, Berry JG, Smith BJ, Esterman AJ. Anonymity or transparency in reporting of medical error: a community-based survey in south Australia. Med J Aust 2004;180:577-580.
4. Schwappach DLB, Koeck CM. What makes an error unacceptable? A factorial survey on the disclosure of medical errors. Int J Qual Health Care 2004;16:317-326.
5. Kachalia A, Shojania KG, Hofer TP, Piotrowski M, Saint S. Does full disclosure of medical errors affect malpractice liability? The jury is still out. Jt Comm J Qual Saf 2003;29:503-511.
6. Chan DK, Gallagher TH, Reznick R, Levinson W. How surgeons disclose medical errors to patients: a study using standardized patients. Surgery 2005;138:851-858.
7. Hingorani M, Wong T, Vafidis G. Patients’ and doctors’ attitudes to amount of information given after unintended injury during treatment: cross sectional, questionnaire survey. BMJ 1999;318:640-641.
8. Hobgood C, Xie J, Weiner B, Hooker J. Error identification, disclosure, and reporting: practice patterns of three emergency medicine provider types. Acad Emerg Med 2004;11:196-199.
9. Waring JJ. Beyond blame: cultural barriers to medical incident reporting. Soc Sci Med 2005;60:1927-1935.
10. American Medical Association. Code of ethics. E-8.121: Ethical responsibility to study and prevent error and harm. Available at: www.ama-assn.org/ama/pub/category/11968.html. Accessed January 22, 2008.
11. Australian Commission on safety and quality in Health Care. Open Disclosure: Health Care Professionals Handbook. Canberra: Commonwealth of Australia; 2003. Available at: www.safetyandquality.org/internet/safety/publishing.nsf/Content/6B75B6A3eA43Ce0FCA2571D50001e19D/$File/hlthcareprofhbk.pdf. Accessed January 7, 2008.
Evidence-based answers from the Family Physicians Inquiries Network